Tuesday, February 26, 2008

It is my belief that evidence-based medicine simplifies, personalizes, and improves medical care. This is in contrast to an article in the NY Times called Miracle Workers? which discussed the challenges doctors have balancing the individual needs for treatment and that treatment suggested by population based research. My letter to the NY Times was as follows:

Mr. Rieff's conclusion that "evidence-based medicine may help the physician avoid the subjective and take a harder line on what is medically useful and what is medically futile...is hardly likely tohelp a doctor treat a person, as opposed to that person's disease" is wrong. Evidence-based medicine at a minimum holds doctors accountable to the latest research which often takes seventeen years before becoming common practice in your doctor's office. Contrary to his conclusion, evidence-based medicine makes it easier to treat each patient as an individual. It simplifies the doctor's decision making process and allows a basic starting point for each person's treatment and then allows the doctor to investigate what makes that person a unique exception. In a country that continually ranks last among industrialized countries in keeping its citizens healthy, evidence-based medicine helps not only improve the quality of healthcare delivered in this country but also helps preserve the sacred doctor-patient relationship in a time more crucial than ever as confusion and frustration abounds as individuals are increasingly inundated with drug ads and accessing a plethora of both good and bad medical information on the web.

Sunday, February 24, 2008

An arbitration judge slapped for profit health insurer Health Net with a judgment of $9 million in favor of a breast cancer patient who had her policy canceled as she underwent chemotherapy. What is frightening is the case highlighted the shameful practices of for profit health insurers. This patient, who had other insurance prior to Health Net, appears to have been aggressively courted by its sales force to switch because it would save her money. It certainly didn't save her from grief as see was saddled with over $100,000 in medical expenses, stopped chemotherapy for months until she could find a charity to cover costs, and unnecessarily worrying about whether she could get the right care, even though in good faith she bought coverage to avoid all of this.

It is a worrisome trend in California, which could be a sign of things to come across this country. Insurers under pressure from employers to slow rising healthcare costs while also seeing double digit rate increases in medical expenses are trying to find ways to do both. Just skipping the ethical discussion of whether for profit insurers should be in the business of healthcare, as any household, business, and government that expects to do well should know, what you bring in (income or revenues) must be more than what you pay out (bills or expenses). It appears insurers are trying to cancel policies for patients, who don't disclose their medical conditions (known as pre-conditions) on their applications retro-actively. According to the LA Times article, Health Net, like many other insurers do so because it is "necessary to hold down costs by weeding out people who may have failed to disclose pre-existing conditions on applications for coverage. They say cancellations happen infrequently." Wellpoint, one of the nation's largest for profit insurers is in favor of changing this practice as is Health Net. Blue Shield had no comment.

What does this mean to you? While the practices illustrated in this case clearly are very disturbing, particularly giving bonuses to staff for meeting a set goal of revoking policies, it shows that insurers are having a difficult time balancing astronomical healthcare expenses and the inability to raise premiums to cover this. As a result, they are more aggressive and critical about who to insure. Without healthcare reform, it is easy to see what will happen. Those with even the slightest problem, like being overweight or obese, will be denied coverage. Those with existing medical problems won't be able to get coverage at all. In fact, ironically the only people who will be able to get coverage are the young and healthy, the group of people that can't afford coverage or are not required to have coverage to offset those who are ill. The underlying premise of insurance, that all chip in to cover those who have an adverse outcome, does not apply in the healthcare industry.

It is clear that there will be fewer insurers as weaker ones drop out of providing health insurance. But unless insurers can balance the revenue and expense equation, the end of the story is simply this, the government will step in and need to provide either financial guarantee and backing like they do for flood insurance or complete government takeover of the insurance industry. It's easy to bash insurance companies and their egregious behavior should not be condoned or tolerated, but is it a sign of how desperate the situation is in our healthcare system which is the most dysfunctional in the world?

Monday, February 18, 2008

This year health care reform has become one of the issues in the race for the White House. While the candidates tout their own plans while criticizing their opponents, the real question is, what issues are vitally important? As doctors, we don't lose sight of the most critical elements, the ABCs, airway, breathing, and circulation, in an emergency. With healthcare reform, focusing on the essentials can clarify what would otherwise be a confusing situation. Improving our healthcare system will require the following issues be recognized and addressed.

We are not getting the most value out of our healthcare dollars. Repeatedly we spend the most per capita than any other industrialized country in the world and have the worst outcomes. A recent 2007 report by the National Committee for Quality Assurance found that 75,000 insured Americans died prematurely because they did not get level of care observed in the top performing health plans. Had they been enrolled, they would be alive today. If we continue to fund a system that rewards mediocrity we will have failed. We should reward those hospitals, doctor groups, and insurers, that already consistently deliver the right care at the right time and support others to improve quickly.

Our healthcare system's financial incentives need to change. The number of primary care physicians is inadequate to meet future demand. Current and future retirees are living longer than a generation ago and also developing more chronic illnesses. At the same time, fewer graduates wish to pursue this specialty due to high medical school loans and lower reimbursement compared to specialists. Doctors get paid to perform procedures and not to think or provide counsel which disadvantages the primary care specialties. In 2003, of those resident physicians completing a three-year residency program only 27 percent planned to be internists, down sharply from 54 percent in 1998. Studies have shown that countries, healthcare organizations, and individuals who mainly rely on primary care physicians do better with less expense.

Everyone must be required to have healthcare insurance. The fundamental truth about insurance is that everyone needs to take on the responsibility for the minority who are at risk for an adverse outcome. If health insurance was not mandatory, individuals would simply jump in when expensive medical care was needed (i.e. pregnancy, cancer) and leave when the situation improved. Healthcare costs would increase exponentially. Preventing this adverse selection will mean everyone must pay into the system.

Healthcare isn't cheap. In fact, many Americans have discovered that health costs are the leading cause of personal bankruptcy. Yet odds are very good that you will. The American Cancer Society predicts that a man has a 1 in 2 chance and a woman a 1 in 3 chance of developing a cancer sometime during his or her lifetime. This calculation excludes patients with the more common forms of skin cancer like basal cell cancer and squamous cell cancer. Remember cancer is America's second leading cause of death. Expect to need doctors and hospitals sometime in the future.

Finally, don't let the government run healthcare. A single payer solution would put the healthcare delivery system at the mercy of political whims and the budget process. Would you like to be hospitalized only to discover that the federal budget and the funds used to provide your care were being debated or traded for other programs the President and Congress felt to be more important for their constituents and agenda? Instead, the government should provide incentives to those whom the market would not normally enroll, guarantee insurability, set up a large insurance pool or trust to benefit from the economies of scale, and assist those who need help and who don't currently qualify for the Medicare and Medicaid programs.

This checklist of important issues, while far from comprehensive, distills the debate into key elements that are vital for healthcare reform. To be successful we will need those who provide care to do deliver care more consistently and regularly to that of recommended guidelines, a deliberate rebuilding of our insufficient primary care workforce, require an individual mandate for all Americans, and elect government leaders who support the insured marketplace to that provides coverage for all. We know what to do. We must act quickly. Without these important and essential interventions, we are simply allowing our critically ill healthcare system to slowly wither away on life support.

Saturday, February 16, 2008

Are large corporations like Wal-mart the answer to solving America's healthcare crisis? Certainly it and other organizations like Federal Express did far better than the government by resuming operations within days compared to weeks after Hurricane Katrina. A recent piece titled Wal-Mart: The New Washington is thought provoking. Excerpts from the NY Times article.

While Congress wrings its hands over higher health care costs, Wal-Mart vowed to save companies $100 million this year by processing their prescription drug claims. (It already sells generic versions of prescription drugs for just $4, well below the national average.)

Wal-Mart, H. Lee Scott Jr., said in an address to employees two weeks ago, “We live in a time when people are losing confidence in the ability of government to solve problems.” But Wal-Mart, he said, “does not wait for someone else to solve problems.”

“With their unique combination of scale and speed they are able to leave any government agency in the dust,” said Amory Lovins, chairman and chief scientist at the Rocky Mountain Institute, an energy research group.

“Wal-Mart is trying to assume the responsibility that their size confers on them,” said Len Nichols, health economist at the New America Foundation, which supports universal health coverage. “It’s a challenge to the government to step up to the plate.”

Take the case of electricity-sipping compact fluorescent light bulbs. Since Wal-Mart began heavily marketing them two years ago, it has sold 145 million bulbs, saving enough electricity, it says, to forestall the need for three coal-fired power plants in the United States.

Now Wal-mart hasn't been the perfect corporate citizen. In late 2005, the revelation of a memo reinforced the belief that it didn't care about its workers when it indicated slowing healthcare costs by discouraging unhealthy people from applying for work. Others have maintained with the low wages and skimpy employee benefits, that Wal-mart was simply using the state and federal Medicaid programs to pick up their employees healthcare costs.

Nevertheless, its recent behavior over the past few years (as well as the actions of other large corporations), seems to suggest that these companies are finding that being part of the solution whether healthcare or environmental concerns is not only socially responsible but also financially sound. An article in Fortune magazine titled Business is Back reviewed the rise of businesses and CEOs to step back into the public eye after being embarrassed by a variety of scandals (think Enron and MCI-Worldcom) and lack of public interest after 9/11.

In my opinion, any healthcare reform will require these large corporations, who purchase the vast majority of health insurance, not only to demand better care for their employees but also to teach the healthcare system on what can be done to improve the speed, reliability, and efficiency of a system too antiquated and failing on every conceivable measure with respect to quality, access and costs.

If our healthcare system can learn from large corporations and large corporations can continue to be mission driven and responsible corporate citizens, you will see a healthcare system far better than those of other countries as the final result will be a uniquely American solution.

Wednesday, February 13, 2008

An excellent NY Times opinion piece titled Clinton, Obama, Insurance shows quite well that his concept of making insurance affordable and not requiring everyone to have health insurance, in fact, is far worse than the proposal by Senator Clinton.

An analysis found that a plan without mandates, similar to the Obama plan, would cover about half of the 47 million uninsured and cost taxpayers $102 billion per year. An identical plan with mandates, similar to the Clinton plan, would cover 45 million of the uninsured — essentially everyone — at a taxpayer cost of $124 billion. Obama-type plan cost $4,400 per newly insured person. Clinton-type plan only $2,700.

Obama's claim that people will buy health insurance when affordable is plain wrong and naive. Without an individual mandate, that is a mandatory requirement to buy health insurance, those who will buy it will be those who need it. those who are ill or the sickest. Naturally, this will drive costs to be astronomical and make insurance even more unaffordable. Although I'm sure Senator Obama has plenty of healthcare advisors, They have conveniently ignored the basic concept of shared responsibility, which is taught in introductory insurance classes.

As the opinion piece notes:

Mr. Obama claims that people will buy insurance if it becomes affordable. Unfortunately, the evidence says otherwise.

After all, we already have programs that make health insurance free or very cheap to many low-income Americans, without requiring that they sign up. And many of those eligible fail, for whatever reason, to enroll.

An Obama-type plan would also face the problem of healthy people who decide to take their chances or don’t sign up until they develop medical problems, thereby raising premiums for everyone else. Mr. Obama, contradicting his earlier assertions that affordability is the only bar to coverage, is now talking about penalizing those who delay signing up — but it’s not clear how this would work.

Out of all the presidental nominees, Senator Clinton has the most carefully constructed and comprehensive healthcare reform plan. Don't let the 30 second soundbites and poison words from the 1990s fool you. This is not the same plan. See for yourself at health08.org which is setup by the Kaiser Family Foundation.

Thursday, February 7, 2008

A Dutch research study found that perhaps over the long-term smokers or obese patients are less expensive to treat than thin and healthy individuals. Although many have assumed that addressing obesity and smoking would save money, this study suggests otherwise. Researchers believe that obese patients, who had more cases of diabetes, and smokers and diabetics, who had more cases of heart disease, died sooner. Those that were healthy lived longer but suffered from debilitating illnesses like Alzheimer's or strokes which in the long run ended costing more. Findings were as follows:

healthy people lived 84 years, cost from age 20 on about $417,000

smokers lived about 77 years, cost about $326,000

obese people lived about 80 years, cost was $371,000

What does this mean? A couple of caveats. First, the research was done on Dutch data, both on how common various diseases were as well as the cost of illness. These values don't necessarily mean the same result would occur in the United States. Since the Netherlands ranks better than the United States in keeping people healthy, it is likely that even the healthy group doesn't live as long as we would expect. The second caveat is perhaps an intervention needs to be made for those that are thin and healthy to prevent them from having strokes and Alzheimers.

Sunday, February 3, 2008

* "Obesity is a natural extension of an advancing economy. As you become a First World economy and you get all these labor-saving devices and low-cost, easily accessible foods, people are going to eat more and exercise less," health economist Eric Finkelstein told AFP. * "When you have a first-rate medical system that can cure the diseases that obesity promotes, you no longer need to worry so much about being obese," he told AFP. * "People make choices, and some people will choose a weight that the public health community might be unhappy about. Why should we try to make them thinner?" Finkelstein said.

I have a couple of problems with the above comments. While clearly more Americans are overweight and obese than previous generations. I doubt that it people are choosing an unhealthy weight. The issue is that the environment around them, specifically the food options are far larger in size and loaded in calories than in the past. Check how serving sizes have changed over the past two decades by taking the Portion Distortion quiz.

In my experience, many of my patients who are obese actually didn't have a weight problem as a young adult (i.e. high school graduate), but years later. The most common cause was inactivity and eating too much (i.e. supersizing everything). Many didn't see much of a problem until I calculated their body mass index.

A first-rate medical system does undoubtedly fix the problems caused by obesity. A first-rate healthcare system, however, should prevent the obesity problem to begin with. Unless we focus on keeping people healthy instead of treating the problems after they have occurred, the next generation of Americans will be the first not to live as long as their parents.

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